PROJECT SUMMARY/ABSTRACT Project 1 ? Understanding Recent Trends in Mortality and Morbidity The goal of this project is to understand the deterioration in health among middle-aged American men and women, especially among white non-Hispanics ? only recently brought to light. After three decades of decline, all-cause mortality rates for white non-Hispanics aged 45?54 have been on the rise since 1998. The increase has been driven by drug and alcohol poisonings, suicides, and cirrhosis and alcoholic liver disease. If white non-Hispanic mortality rates had continued to decline at 1.8 percent a year after 1998 ? the average rate of decline for whites in the previous two decades ? about 500,000 deaths would have been avoided through 2013, a number comparable to cumulative AIDS deaths in the U.S. There has been no corresponding change in the rate of mortality decline for non-Hispanic blacks or for Hispanics. In the same age group, morbidity among white non-Hispanics has increased for a range of measures, including self-reported physical and mental health, chronic pain, ability to conduct activities of daily living, including work, self-reports of heavy drinking, and clinically measured liver function. In contrast to the midlife group, mortality and morbidity have continued to improve for those aged 65 and above. The project will drill down into these overall statistics, disaggregating by location, by age, by sex, by occupational and educational groups, and by race and ethnicity, as well as by making comparisons with other wealthy countries. It will also attempt to understand the causes behind the decline in midlife health. There are two broad Specific Aims: (1) to build a public use database for the U.S. and for other rich countries that will be rich enough to document, for the U.S., the geographical distribution of midlife deaths and to link mortality and morbidity patterns, across space and time, to patterns of income, poverty, inequality, employment, unemployment, education and occupation and, internationally, to study the differences and similarities in mortality and morbidity patterns between the U.S. and other rich countries; and (2) to use the spatial and temporal ordering of those data to consider a range of hypotheses and possible determining factors, including (i) diminishing economic opportunity, especially for those with only a high school degree or less education, (ii) increases in pain and morbidity, before and after the marked increase in opioid availability, (iii) changes in occupational structure on reports of pain and other morbidity, and (iv) education itself, in conditioning mortality and morbidity independent of occupation and income. We will test whether hypotheses on economic prosperity, pain and other morbidity, increased availability of opioids, occupation, and education help to explain the differences between the US and other rich countries, and differences between racial and ethnic groups within the U.S.